Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of this practice on 3 December 2015. Breaches of legal requirements were found. After the comprehensive inspection, the practice wrote to us to say what they would do to meet legal requirements in relation to the breaches. We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Drs Macdonald, Guinan, Charles-Jones & Anderson on our website at www.cqc.org.uk

Our key findings were as follows:

• A Disclosure and Barring Service (DBS) check had been carried out to confirm the suitability of all clinical staff for their roles.

• The procedures for the management of vaccines had been reviewed to ensure they were safely managed.

The areas where the provider should make improvements are:

• The procedure around the safe management of vaccines should contain information about how the security of the vaccines is to be maintained.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Drs Macdonald, Guinan, Charles-Jones & Anderson (also known as Lache Health Centre) on 3rd December 2015.

Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

• Staff were aware of procedures for safeguarding patients from the risk of abuse.
• There were systems in place to reduce risks to patient safety, for example, infection control procedures and the management of staffing levels. However, improvements were needed to the recruitment records and systems in place for the safe management of vaccines.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles.

• Patients were overall very positive about the care they received from the practice. They commented that they were treated with respect and dignity and that staff were caring, supportive and helpful.

• Services were planned and delivered to take into account the needs of different patient groups.

• Access to the service was monitored to ensure it met the needs of patients. Patients reported satisfaction with opening hours and said they were able to get an appointment when one was needed.

• The practice sought patient views about improvements that could be made to the service and acted on patient feedback. Information about how to complain was available.

• There were systems in place to monitor and improve quality and identify risk.

We saw an area of outstanding practice:

• The healthcare assistant, practice nurse and practice manager had received awards this year from the West Cheshire Clinical Commissioning Group for Practice Manager of the Year, Carer’s Link of the year and Practice Nurse of the Year. The awards are designed to recognise, highlight, and reward hard work and innovation.

However there were areas of practice where the provider needs to make improvements:

• The provider must ensure that evidence is held at the practice to confirm all clinical staff have received a Disclosure and Barring Service (DBS) check to confirm their suitability for employment.

• The procedures for the management of vaccines need to be reviewed to ensure they are held securely, safely monitored and any concerns are identified, reported, investigated and appropriate action taken.

The areas where the provider should make improvements are:

• Establish a system to check the continuing suitability of GPs by checking the GMC and Performers List.

• Ensure a record is kept of building and equipment checks, the outcome and when they are due to assist in monitoring the safety of the premises and equipment.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice